Application form details APS 2016

PCEC, Perth | 13 – 16 March 2016

TitleNameCurrent Position(s)Current Organisation(s)Work AddressWork PhoneMobileE-mailDate of PhD conferralInstitution conferralYears of Post-Doctoral ResearchRelative to opportunity and to career disruption; e.g., with respect to clinical work, maternity/paternity/carer responsibilitiesExtenuating circumstancesIf applicable, explain why you do not meet the eligibility criteria, or if we should take any circumstances into consideration when evaluating your application.Current Research Field(s) [ ] Basic Science

[ ] Medicine[ ] Physiotherapy[ ] Occupational therapy[ ] Psychology[ ] Nursing[ ] Paediatric pain[ ] Acute pain[ ] Chronic pain[ ] other …….

Current supervisor/mentorResearch achievementsDescribe the achievements and outcomes from your research, from and since your PhD, and their implications for your research field and for society in general.250 word limitTranslational impact (or potential)Give a brief summary of the and outreach activities – eg public lectures etc. actual or potential translational impact of your work on science, clinical practices, policy, industry or technology, consumer care. Highlight your role in achieving these translational outcomes.100 word limit

FundingDescribe your top funding successes, your role in the funding (ie CI/AI) and project, and any translational impact or potential of the research.200 word limit

Best five publicationsList your top significant publications; describe your contribution to them (e.g. writing/management/data analysis/corresponding author, etc.) and why you selected them relative to their impact (e.g., knowledge gain, clinical translation, policy or guideline development, training)200 word limit for each publication.Leadership roles and achievementsList your leadership roles in pain science50 word limitCollaborationsDescribe your key collaborations and your role (e.g., leading research, whether you approached the collaborator or were approached by them).50 word limitTitle for your Rising Star presentation

Abstract for your Rising Star presentation250 word limit